Some of the most difficult pastoral situations that ministers and elders face today revolve around questions of bioethics. Infertile couples seek counsel about pursuing artificial means of reproduction, sick parishioners solicit advice about whether to undergo experimental (but risky and expensive) treatment for a life-threatening illness, and uncertain saints ask when it might be proper to discontinue artificial nutrition and hydration for a permanently unconscious relative. From one perspective, the very fact that we face such questions gives us much to be thankful for: because of great advances in medical technology, we are able to cure physical ailments and prolong life in ways impossible in previous generations. But with these blessings have also come perplexing ethical problems with which previous generations did not have to wrestle. As medical technology continues to progress at astounding speed, ministers and elders can only expect that such problems will become both more complex and more common.
A large part of the difficulty surrounding bioethics questions for Christians is the lack of explicit biblical instruction for dealing with them. It is simply a fact that Scripture provides no specific guidelines about overcoming infertility through in-vitro fertilization or about traveling to Mexico to receive an obscure course of treatment unapproved by the FDA yet offering a faint possibility of cure for an otherwise terminal illness. Making moral choices under such circumstances is difficult, but Christians are not left without resources. Perhaps most crucial is having a solid theological foundation along with the wisdom to perceive the implications of that foundation. Regarding bioethics, perhaps no doctrine is more important than anthropology. Having a biblically-grounded anthropology certainly does not guarantee an easy answer to every bioethical question, but it does provide necessary context for evaluating bioethics conundrums.
In this essay, I reflect upon two aspects of a Christian anthropology particularly important for bioethics. First, I consider the image of God, and then I explore the curse of mortality and the promise of immortality described in Scripture. Both of these matters, we will see, ought to shape profoundly the way in which we approach the pastoral challenges provoked by bioethics.
An understanding of the image of God has been central not only to Reformed anthropology but also to the anthropology of the other major Christian traditions. I focus in this first section upon three aspects of the biblical, Reformed doctrine of the image of God that are foundational for a proper approach to bioethics.
The first aspect may seem rather obvious to many, but it is worth mentioning nonetheless: the doctrine of the image of God reminds us of the inherent value and dignity of every human being. The fact that we bear God's image means that we were created with moral responsibility toward God with the goal of everlasting fellowship with him. Recognition of this simple yet profound truth explains why the conception, birth, dying, and death of every human person are radically different from these same events in the animal world. However biologically similar the origin and end of human and animal life may appear, a world of difference separates them morally. This Christian perspective stands out most starkly in comparison with radical contemporary voices such as that of Peter Singer, whose conflation of human and animal life simultaneously overvalues animals and undervalues human beings (at least those whose disability renders them something less than persons). The ethical implications of these diverse perspectives are clear regarding many controversial social issues, such as abortion, embryonic research, euthanasia, and assisted suicide. Every human beingno matter how small, vulnerable, or sickis worthy of care and protection. These high-publicity social issues probably seem like easy ethical issues to most office-bearers in Reformed churches, but surely there are plenty of temptations for us to live inconsistently with the implications of this aspect of the image of God. We ought to beware, for example, of begrudging the pastoral effort that the disabled, infirm, or dying may demand when we could be devoting time to the healthy and wealthy members or budding seminarians who offer far greater prospects for contributing to the well-being of the church.
Another significant aspect of the image of God that is not as often recognized, but which also has weighty bioethical implications, is the idea that God's image-bearers are inherently social creatures. From the beginning God made his image-bearers "male and female" (Gen. 1:27) and gave them tasksmultiplying and exercising dominion (Gen. 1:28)that are impossible to carry out as solitary individuals. This basic reality remains unchanged in the fallen world and is in fact heightened by our re-creation in the image of God through the work of Christ. We have been "predestined to be conformed to the image of his Son, in order that he might be the firstborn among many brothers" (Rom. 8:29). Christians are not only made to be members of the broader human community but also, and especially, recreated to be members of the redeemed community of the church which will find its consummation in the perfect community of the everlasting heavenly kingdom. To be an image-bearer means to live in mutual responsibility and accountability.
What bioethical situations might prompt ministers and elders to keep such truths in mind? Consider a married couple, for many years unable to have children, who comes seeking guidance about whether they should pursue remedies that promise to be emotionally, physically, and financially trying. Assuming for the moment that they are not considering a remedy that is inherently sinful, what sorts of considerations should their pastor or elders bring to their attention? First, they might be reminded that as God's image-bearers they were made male and female, designed for marriage and called to be fruitful in that relationship. This inherently social aspect of the image should assure them that their desire to have children is healthy and righteous, and they need not feel guilty about pursuing this desire. At the same time, they might also be reminded that the social character of the image of God extends beyond their own familial relationships. They also have responsibilities toward others in the human community and especially toward their fellow saints in the church. Just as Paul himself recognized that having no wife allowed him to serve God in ways that his married colleagues could not (see 1 Cor. 7:7, 32-35; 9:5), so there are certainly opportunities for service in civil society and in the church that those without children may be better able to pursue: serving as missionaries in a dangerous place (or pursuing a socially-beneficial secular calling in a dangerous place), offering regular and generous hospitality for the needy, giving lavishly to the promotion of the gospel, or even adopting a child or children from among the numerous orphaned and abandoned children of the world. Infertile couples, finding one avenue for expressing the social character of the image of God closed to them, can be challenged to see other avenues opening for them. Such considerations do not in themselves provide a quick and easy answer to this couple's original dilemma. But a solid anthropology can help people to see the various dimensions of their moral choice.
This social aspect of the image of God has many other ramifications for bioethics. To mention just one more, it should certainly affect the way in which we counsel people who are contemplating in advance what kind of care they wish to receive should they become incapacitated. A number of options now exist for people to consider. A living will specifies what kind of medical interventions a person desires under particular circumstances if he is unable to make that decision himself. A power of attorney for health care designates an agent to make such medical decisions on behalf of the incapacitated individual. Wisdom suggests that such matters ought to be dealt with in advance and with due reflection, before an emergency or crisis situation occurs. But what sorts of provisions for the future are appropriate? One common concern is that we not be a burden to our family members who will have to care for us or be financially implicated when we reach the last stages of life. The social character of the image of God indicates that this concern is quite proper. Only an image-denying selfishness would make inordinate demands for one's own care and preservation at the expense of the other ongoing responsibilities and financial health of the next generation. Yet concern for the social character of the image of God cuts in the other direction as well. A principal part of this concern is that we ought to care for each other, which includes expending time and money to help family members and Christian brothers and sisters who are in need. We should not only be willing to give such care but also to receive such care. None of us, no matter how strong or wealthy at the moment, is an autonomous individual who can insulate himself from any need for help from others. Taken together, these considerations suggest that planning for our health care future demands a balance that both avoids undue demands upon loved ones and allows them to provide for us in our weakness. This also entails that we not be overly confident in our ability to specify in advance exactly how we think we should be treated, but instead should be willing to entrust important decisions about what kind of care we need to loved ones whose judgment we trust.
One other consideration related to the image of God is important to mention briefly. Though the divine image has been terribly corrupted by the fall into sin, Reformed theologians have generally recognized that it has not been expunged completely (see Gen. 9:6; James 3:9). One of the implications of the lingering remnant of the image of God is the moral knowledge and responsibility of unregenerate humanity. From the beginning, bestowal of the image meant that human beings were moral creatures (see Gen. 1:26, 28 and Eph. 4:24), and retention of the image, however marred, ensures that people continue to know their basic moral responsibilities and their accountability toward God. If human beings are image-bearers by nature, then by nature they know something about God and his moral character. Paul reflected on this reality even concerning the unregenerate in Romans 1:18-32 and 2:14-15. This has implications for bioethics. For one thing, as Christians enter the public health care system in which they necessarily deal with many non-Christians and as they participate in public policy debates about bioethics issues, they may derive confidence from the fact that, at the very least, general revelation impresses upon unbelievers' consciences many truths about the human condition. Of course, unbelievers suppress this knowledge and often deny it, but even when this is the case, Christians can appeal to the inherent dignity of each person and other such truths being confident that all people know that they are true even if they refuse to acknowledge it. Thanks to common grace, however, it is also the case that unbelievers in fact often recognize and live according to the truths of general revelation in their outward lives. Unbelievers often make great contributions to medicine, defend humane bioethical positions, and instill wisdom in people winding their way through the health care maze. In light of these considerations, pastors and elders may find occasion to offer encouragement to their anxious sheep who must deal with medical issues in reliance upon and collaboration with those who do not share their faith.
A second issue in anthropology that has far-reaching ramifications for bioethics is the nature of human mortality and the blessing of immortality that comes in Christ. Since issues related to illness and dying are among the most common and controversial in contemporary bioethics, having a proper grasp of the nature of death is of particular importance. Surely all people by general revelation know important things about the character of death, but Scripture clarifies crucial aspects of this matter and reveals what general revelation cannot relate, namely, that death has been defeated through the work of Christ. In this section we will consider how these truths should mold the way that Reformed pastors and elders instruct all of their sheep about the inevitable reality of death and especially those for whom death is imminent.
Crucial to a biblical anthropology is that fallen human beings are mortal. This may appear to be a rather banal claim, since human mortality seems to be a fact that no one would dare to deny. And yet many people do try to suppress or even to overcome it. The United States of America has arguably the best health care system in the world, offering prospects for treatment of illness and preservation of life never before seen in human history. But polls tell us that discontentment with the health care system is one of the predominant concerns of Americans today, and this sour mood promises to shape much of the rhetoric of the 2008 presidential campaign. The best medical care in the worldyet people continue to get sick, treatments continue to fall short, people continue to die. As long as these things happen, there will never be satisfaction. The more that medicine can do, the higher people's expectations become. The stupendous accomplishments of modern medicine combined with a stubborn refusal to accept the fact of human mortality has in fact spawned the recent rise of "transhumanism," a movement whose goal is to transcend the present limits of human nature and to transform us into a new kind of death-defying being.
The present cultural discontentment with advanced modern medicine is put into stark perspective by a biblical anthropology. There is, of course, nothing wrong with seeking further progress in fighting disease and seeing medicine's achievements benefit more people. However, a biblical anthropology confronts us with the fact that human suffering and death are not obstacles that might be overcome by our own ingenuity, but a curse and punishment placed upon the human race by God on account of sin. Human effort can never overcome what God has ordained. For Christians, the question cannot be whether we will suffer in this life, but with what attitude we will suffer. The question is not whether we will die, but how we will prepare to die, both when it seems far off and when it seems near. Ministers and elders must guard themselves against the temptation to join in the contemporary discontentment and instead strive to refocus the church's sights on gaining a proper attitude toward our inevitable suffering and death.
What is a proper attitude toward death? A biblical anthropology instructs us, first of all, that death is a horrible and frightening thing. Human death is not something natural, in the original sense of how God created things to be, but is the result of Adam's fall into sin (Gen. 2:17, 3:19; Rom. 6:23). As such, death is a curse, a judgmentand it is a judgment and curse of the most horrifying kind. As the Reformed doctrine of the covenant of works teaches, God originally called man to lifenot to a continuing life in the Garden, but to an everlasting life of confirmed righteousness in eschatological glory. When God threatened death upon disobedience, then, he was threatening much more than temporal death in this world, the dissolution of soul and body. He was threatening an everlasting death of confirmed condemnation in eschatological torment.
Unbelievers are surely not ignorant of this grim reality. Romans 1:32, concluding a long discourse on how people pervert the natural knowledge of God and his law, states frankly: "Though they know God's decree that those who practice such things deserve to die, they not only do them but give approval to those who practice them." Little wonder it is, then, that for many people death has been a subject to be avoided and a reality to be denied even when its onset is at hand. Some readers will be familiar with John Gunther's 1949 book, Death Be Not Proud, an account of his seventeen-year-old son's battle with and death from a brain tumor. Though this book is moving and filled with characters who are admirable in many respects, it is striking to observe that neither the doctors nor his parents ever told this teenage boy that he was going to die. The author-father states explicitly that they repeatedly deceived him about the state of his cancer and the success of the treatments, and he clearly considers this to have been the humane and obvious course of action. Gunther explains that they did not want to take away his hope nor derail his courage. But can a person exercise true hope or true courage when he is, perhaps through no fault of his own, deluded about the truth and acting upon false premises? Surely, Christians must be encouraged to face the truth about deathincluding their own. Death is far too momentous a thing to be ignored or denied. The reality of death must be confronted and dealt with; otherwise there can be no experience of hope or exhibition of courage.
Cultural mores seem to have swung in the opposite direction since the days of Gunther's memoir, however. Now conventional wisdom tells us that we must indeed face up to our death and the feelings of grief that dying evokes. Due to the efforts of figures such as Elisabeth Kübler-Ross and the hospice movement, the topics of death and dying have been brought into the open in ways that they were not before. Undoubtedly, this development has had some beneficial results from an earthly point of view, such as in improving relationships among family members of the dying as a result of open and honest conversation. But other aspects of this development make it decidedly insufficient and even unhelpful from the perspective of biblical anthropology. Most importantly, it holds out the goal of deaths that are inherently peaceful and acceptable as part of the natural course of things, with or without faith in Christ (different programs have different views about the place of religion in the dying process). Yet given the reality of death as a dreadful curse and a gateway to everlasting punishment, no death can be truly peaceful that is viewed apart from Christ. Whatever honesty is gained by facing up to the approach of death is lost by the need to package death as something other than the divine judgment that it is.
When they acknowledge the reality and inevitability of death on the one hand and the fearsome character of death on the other, Christians take an honest perspective. But there is no comfort or encouragement in this per se. Ministers and elders are able to offer encouragement in the face of death only in light of Christ's great acts of redemption. The Lord Jesus Christ became one of us in body and soul, endured human suffering beyond what any of us will suffer, and experienced not only the dying process but even death itself, through the separation of soul from body and the burial of his body in a tomb. And, in enduring all of these things, he knew not only temporal death but also eschatological death, as he took upon himself the wrath of his Father against sin. By faith we have died and been buried with him and know that he has died once and for all on our behalf (Rom. 5:8; 6:3-4). But even this would be of little comfort were it not for Christ's resurrection, by which he, in human flesh, attained the eschatological life to which Adam was originally called. Scripture therefore announces that death has been defeated (1 Cor. 15:54-57) and the one who has the power of death has been destroyed (Heb. 2:14-15). Even now we have been raised with Christ (Rom. 6:5; Col. 3:1-4) and look forward with great assurance to our own bodily resurrection on the last day (1 Cor. 15:20-23).
At this point a biblical anthropology is transformed by biblical soteriology and eschatology. For those who belong to Christ, the human condition has been altered in fundamental ways, and in no case is this more evident than in regard to death. Believers remain subject to death in this world, and their deaths will look the same biologically as the deaths of unbelievers. But they should be urged to approach death with a radically different attitude; for though death still produces godly grief in them, it has lost its sting. Death has become the gateway to heaven and, one day, to the resurrection of the body. Reflecting the Christian's new attitude, the Apostle Paul could honestly and openly contemplate his own death and nevertheless acknowledge death as preferable to life in this world due to the prospect of being with Christ (Phil. 1:20-23; 2 Cor. 5:6-8). Believers may face death with true hope, that is, the absolute assurance of good things to come, not (as commonly in our everyday speech) the possibility (however remote) of a happy ending. And believers may face death with true courage, that is, boldness and perseverance in the face of great trial because they know that God will not let them be tempted in this life beyond what they can bear and will bring them safely to their everlasting rest.
Reflecting upon this anthropological transformation that the work of Christ effects provides key resources for shepherding God's children through the valley of the shadow of death. We may remind those whose suffering is severe, for whom the idea of assisted suicide or mercy killing seems attractive, that Christ has suffered every human affliction as their great high priest (Heb. 2:17-18), has called us to suffer with him for a little while (Rom. 8:17), and has promised never to leave us or forsake us (Heb. 13:5). We are precious to God in our dying (Ps. 116:15), and those dying in Christ are blessed (Rev. 14:13). But these great truths of a transformed anthropology may also serve to remind dying saints who still have a strong desire to live that there is a time to die. When exactly is the right time to forego further treatment is a very difficult question that cannot be explored here. But such a decision can be a godly one precisely because in Christ we have come to recognize that life here on earth is not the highest good. It is surely not something to which we should cling tenaciously no matter what the cost. There is a time to recognize that our labors on earth are ending, by God's will, and that we may look forward with joy to our imminent departure to be with Christ.
The recent advances in modern medicine have indeed given birth to a slew of new and challenging ethical issues that have also become trying pastoral issues for the church. Knowing biblical, Reformed doctrine does not eliminate the need for wisdom in order to understand the moral significance of particular circumstances and the spiritual state of particular saints. But being grounded in a sound anthropology, on matters such as the image of God and human mortality and immortality, provides indispensable resources by which the shepherds of Christ's church may guide the flock through many of the hardest situations that they will face. Contemplating the implications of our anthropology is a task that should engage all of us as office-bearers as we navigate through increasingly complicated medical waters.
David VanDrunen, a minister in the Orthodox Presbyterian Church, is the Robert B. Strimple Professor of Systematic Theology and Christian Ethics at Westminster Seminary California. His book on bioethics and the Christian life is due to be published by Crossway in 2009. Ordained Servant, April 2008.